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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701278
Report Date: 06/07/2023
Date Signed: 06/07/2023 03:48:38 PM


Document Has Been Signed on 06/07/2023 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CHEROKEE RETIREMENT HOMEFACILITY NUMBER:
392701278
ADMINISTRATOR:SINGH, JAKTARFACILITY TYPE:
740
ADDRESS:4124 CHEROKEE RDTELEPHONE:
(209) 518-1908
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY:15CENSUS: 13DATE:
06/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Rick ReedTIME COMPLETED:
03:50 PM
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On 6/7/23 at approximately 2:15pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a pre-licensing change of ownership. LPA Jensen met with current Licensee Rick Reed and explained the purpose of today's visit. Prospective Licensee Jaktar Singh was unable to attend on this date.

Licensing Program Analyst Jensen toured the facility the facility and the grounds. There are 2 buildings on the grounds. The main building has 7 bedrooms and the adjacent building has 3 bedrooms. The licensee has submitted an application for 15, 10 ambulatory residents and 5 non-ambulatory. There is a hospice waiver for 3. There are currently 13 residents. There are currently 12 non-ambulatory residents and 1 non-ambulatory resident. There are no bodies of water on the property. New lighting has been installed all around the exterior of the facility.

The water temperature in both buildings was measured at 107 degrees which is within the required regulatory range of 105 - 120 degrees. The thermostat was set at 75 degrees for the comfort of the residents. The facility maintains in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. All bedrooms were observed to have night stands, dressers, lamps and chairs. The fire extinguisher was last serviced in May of 2023 and is in compliance. The carbon monoxide detectors were tested and found to be in good working order. The smoke detectors are hard wired.

The STD 850 states that there is 1 building on the property which is not accurate. The Licensee has not passed the pre-licensing inspection at this time as the STD 850 needs correction. It is anticipated that this will take approximately 10 days to correct at which time the Department will return to complete the pre-licensing inspection and component III.

An exit interview was conducted and a copy of this report was given to Rick Reed.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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